Systems and methods for programming neuromodulation waveform

ABSTRACT

This document discusses, among other things, systems and methods for programming neuromodulation therapy to treat neurological or cardiovascular diseases. A system includes an input circuit that receives a modulation magnitude representing a level of stimulation intensity, a memory that stores a plurality of gain functions associated with a plurality of modulation parameters, and a electrostimulator that may generate and deliver an electrostimulation therapy. A controller may program the electrostimulator with the plurality of modulation parameters based on the received modulation magnitude and the plurality of gain functions, and control the electrostimulator to generate electrostimulation therapy according to the plurality of modulation parameters.

CLAIM OF PRIORITY

This application is a continuation of U.S. application Ser. No.15/790,977, filed Oct. 23, 2017, which claims the benefit of priorityunder 35 U.S.C. § 119(e) of U.S. Provisional Patent Application Ser. No.62/425,855, filed on Nov. 23, 2016, each of which is herein incorporatedby reference in its entirety.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is related to commonly assigned U.S. Provisional PatentApplication Ser. No. 62/425,848, entitled “SYSTEMS AND METHODS FORPROGRAMMING A NEUROMODULATION THERAPY”, filed on Nov. 23, 2016, which isincorporated herein by reference in their entirety.

TECHNICAL FIELD

This document relates generally to medical systems, and moreparticularly, but not by way of limitation, to systems, devices, andmethods for programming neuromodulation waveform.

BACKGROUND

Neuromodulation, also referred to as neurostimulation, has been proposedas a therapy for a number of conditions. Examples of neuromodulationinclude Spinal Cord Stimulation (SCS), Deep Brain Stimulation (DBS),Peripheral Nerve Stimulation (PNS), and Functional ElectricalStimulation (FES). For example, SCS has been used to treat chronic painsyndromes. Some neural targets may be complex structures with differenttypes of nerve fibers. An example of such a complex structure is theneuronal elements in and around the spinal cord targeted by SCS.

Implantable neuromodulation systems have been applied to deliver such atherapy. An implantable neuromodulation system may include animplantable neuromodulator, also referred to as an implantable pulsegenerator (IPG), and one or more implantable leads each including one ormore electrodes. The implantable neuromodulator delivers neuromodulationenergy through one or more electrodes placed on or near a target site inthe nervous system. An external programming device may be used toprogram the implantable neuromodulator with stimulation parameterscontrolling the delivery of the neuromodulation energy.

Electrical stimulation energy may be delivered from the implantableneuromodulator to the electrodes to stimulate neural tissue in the formof an electrical pulsed waveform. The configuration of electrodes usedto deliver electrical pulses to the targeted tissue constitutes anelectrode configuration, with the electrodes capable of beingselectively programmed to act as anodes (positive), cathodes (negative),or left off (zero). In other words, an electrode configurationrepresents the polarity being positive, negative, or zero. Otherparameters that may be controlled or varied include the amplitude, pulsewidth, and rate (or frequency) of the electrical pulses provided throughthe electrode array. Each electrode configuration, along with theelectrical pulse parameters, constitutes a modulation parameter set foruse in an electrostimulation therapy.

SUMMARY

Programming of neuromodulation therapy, such as SCS, conventionallyinvolves separate and independent programming of each of a multitude ofmodulation parameters such as parameters that define a modulationwaveform. Modulation parameters are conventionally programmed in alinear fashion such that the stimulation energy delivered to the tissueis linearly proportional to the current or voltage amplitude of astimulation pulse. However, some biological systems may demonstrate anonlinear response to electrostimulation. For example, when theelectrostimulation energy is below a particular threshold, nophysiological response would be induced. However, whenelectrostimulation energy exceeds another threshold, unwanted sideeffects such as pain may occur. Additionally, some neuromodulationsystems may include electrostimulation configuration and complexmodulation waveforms. These modulation waveforms may be characterized bya large amount of modulation parameters. Programming of theneuromodulation therapy may require adjusting these modulationparameters individually and separately, and transmitting the modulationparameters to an IPG. This may put a burden on a telemetry system thatenables communications between the IPG and the programming device. Thepresent inventors have recognized that there remains a demand forimproved systems and methods to program an electrostimulation system fordelivering electrostimulation therapy, particularly to more efficientlyprogram neuromodulation waveform.

Example 1 is a system for providing electrostimulation to a patient. Thesystem comprises an input circuit configured to receive informationcorresponding to a user input of a modulation magnitude representing alevel of stimulation intensity, a memory configured to store a pluralityof gain functions associated with a plurality of modulation parameters,an electrostimulator configured to generate an electrostimulationtherapy for delivery to the patient, and a controller. The plurality ofgain functions each defines a correspondence between values of amodulation parameter and a plurality of modulation magnitudes. Thecontroller may program the electrostimulator with the plurality ofmodulation parameters based on the received modulation magnitude and theplurality of gain functions, and control the electrostimulator to elicitthe electrostimulation therapy according to the plurality of modulationparameters.

In Example 2, the subject matter of Example 1 optionally includes theinput circuit that may be configure to receive the modulation magnitudewithin a magnitude range based on a perception threshold.

In Example 3, the subject matter of Example 2 optionally includes themagnitude range that is further based on a maximum tolerable threshold.

In Example 4, the subject matter of any one or more of Examples 1-3optionally includes a modulation magnitude equalizer that may produce aplurality of modulation magnitudes representing a plurality of levels ofstimulation intensity within a specific range.

In Example 5, the subject matter of any one or more of Examples 1-4optionally includes the electrostimulator that is further configured togenerate a spinal cord stimulation (SCS) therapy or a deep brainstimulation therapy.

In Example 6, the subject matter of any one or more of Examples 1-5optionally includes the electrostimulator that is further configured togenerate a cardiac or neural stimulation therapy to treat acardiovascular disease.

In Example 7, the subject matter of any one or more of Examples 1-6optionally includes the plurality of gain functions that are associatedwith a plurality of temporal modulation parameters comprising at leastone of a pulse amplitude; a pulse width; a pulse frequency; or a burstintensity.

In Example 8, the subject matter of any one or more of Examples 1-7optionally includes the plurality of gain functions that are associatedwith a plurality of morphological modulation parameters respectivelydefining one or more portions of a stimulation waveform morphology.

In Example 9, the subject matter of Example 8 optionally includes theplurality of morphological modulation parameters that may includemorphologies of at least first and second pulses of a multiphasicstimulation waveform. The plurality of gain functions comprise a firstgain function defining a modulation parameter of the first pulse atvarious modulation magnitudes, and a second gain function defining amodulation parameter of the second pulse at various modulationmagnitudes.

In Example 10, the subject matter of any one or more of Examples 1-9optionally includes the plurality of gain functions that are associatedwith a plurality of spatial modulation parameters including selectedactive electrodes and stimulation energy fractionalization over theselected active electrodes.

In Example 11, the subject matter of any one or more of Examples 1-10optionally includes: the modulation magnitude that corresponds to a userinput for selecting a first modulation program or deselecting a secondmodulation program, wherein the first and second modulation programseach includes an aggregation of respective plurality of modulationparameters; and the controller that may be configured to (a) program theelectrostimulator with the selected first modulation program, and tocontrol the electrostimulator to elicit the electrostimulation therapyaccording to the selected first modulation program, or (b) to withholdthe electrostimulation therapy according to the deselected secondmodulation program.

In Example 12, the subject matter of Example 11 optionally includes themodulation magnitude corresponds to a user input for selecting amodulation program associated with a physiological state or a physicalactivity. The modulation program may comprise at least one of: amodulation program for sleep state; a modulation program for awakeningstate; or a modulation program for a specific physical activity level.

In Example 13, the subject matter of any one or more of Examples 1-12optionally includes the plurality of gain functions that may includelinear, piece-wise linear, or non-linear functions of the modulationmagnitude.

In Example 14, the subject matter of any one or more of Examples 1-13optionally further includes an ambulatory medical device (AMD) thatincludes at least a portion of one or more of the electrostimulator orthe controller, and an external programmer device configured to becommunicatively coupled to the AMD. The external programmer device mayinclude at least a portion of the memory.

In Example 15, the subject matter of any one or more of Example 1-14optionally includes the modulation magnitude relative to a baselineelectrophysiological measurement,

Example 16 is a system for providing electrostimulation to a patient.The system comprises an input circuit configured to receive informationcorresponding to a user input of at least first and second modulationmagnitudes each representing a level of stimulation intensity. The firstmodulation magnitude may be represented as a value relative to abaseline electrophysiological measurement, and the second modulationmagnitude may be represented as a value relative to a perceptionthreshold. The system comprises a memory configured to store a pluralityof gain functions associated with a plurality of modulation parameters,an electrostimulator configured to generate an electrostimulationtherapy for delivery to the patient, and a controller. The plurality ofgain functions each defines a correspondence between values of amodulation parameter and a plurality of modulation magnitudes. Thecontroller may program the electrostimulator with the plurality ofmodulation parameters based on the received modulation magnitude and theplurality of gain functions, and control the electrostimulator to elicitthe electrostimulation therapy including a sub-perception stimulationaccording to the first modulation magnitude and a supra-perceptionstimulation according to the second modulation magnitude.

Example 17 is a method for providing electrostimulation to a patient viaan ambulatory medical device (AMD) communicatively coupled to anexternal programmer device. The method comprises steps of: receivinginformation corresponding to a user input of a modulation magnituderepresenting a level of stimulation intensity; establishing a pluralityof gain functions associated with a plurality of modulation parameters,the plurality of gain functions each defining a correspondence betweenvalues of a modulation parameter and a plurality of modulationmagnitudes; determine values for the plurality of modulation parametersusing the received modulation magnitude and the plurality of gainfunctions; programming the plurality of modulation parameters, via theexternal programmer device, with the determined values; and generatingthe electrostimulation therapy, via the AMD, according to the pluralityof modulation parameters.

In Example 18, the subject matter of Example 17 optionally includes thereceived modulation magnitude that is within a magnitude range based onone or more of a perception threshold or a maximum tolerable threshold.

In Example 19, the subject matter of any one or more of Examples 17-18optionally includes generating at least one of a spinal cord stimulation(SCS) therapy, a deep brain stimulation therapy, or a cardiac or neuralstimulation therapy.

In Example 20, the subject matter of any one or more of Examples 17-19optionally includes establishing gain functions associated with aplurality of temporal modulation parameters comprising at least one of:a pulse amplitude; a pulse width; a pulse frequency; or a burstintensity.

In Example 21, the subject matter of any one or more of Examples 17-20optionally includes establishing the gain functions associated with aplurality of morphological modulation parameters respectively definingone or more portions of stimulation waveform morphology.

In Example 22, the subject matter of any one or more of Examples 17-21optionally includes establishing the gain functions associated with aplurality of spatial modulation parameters including selected activeelectrodes and stimulation energy fractionalization over the selectedactive electrodes.

In Example 23, the subject matter of any one or more of Examples 17-22optionally includes steps of receiving a modulation magnitude thatcorresponds to a user input for selecting a first modulation program ordeselecting a second modulation program, the first and second modulationprograms each including an aggregation of respective plurality ofmodulation parameters. The plurality of modulation parameters correspondto the selected first modulation program. The electrostimulation therapymay include generating an electrostimulation therapy according to theselected first modulation program, or withholding the electrostimulationtherapy according to the deselected second modulation program.

This summary is intended to provide an overview of subject matter of thepresent patent application. It is not intended to provide an exclusiveor exhaustive explanation of the disclosure. The detailed description isincluded to provide further information about the present patentapplication. Other aspects of the disclosure will be apparent to personsskilled in the art upon reading and understanding the following detaileddescription and viewing the drawings that form a part thereof, each ofwhich are not to be taken in a limiting sense.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings, which are not necessarily drawn to scale, like numeralsmay describe similar components in different views. Like numerals havingdifferent letter suffixes may represent different instances of similarcomponents. The drawings illustrate generally, by way of example, butnot by way of limitation, various embodiments discussed in the presentdocument.

FIG. 1 illustrates, by way of example and not limitation, aneuromodulation system and portions of an environment in which theneuromodulation system may operate.

FIG. 2 illustrates, by way of example and not limitation, an externalremote controller (RC) that telemetrically controls the IMD.

FIGS. 3A-3B illustrate, by way of example and not limitation, variousexamples of an intermediate controller that may be used by a user tocontrol the generation of the modulation waveform.

FIG. 4 illustrates, by way of example and not limitation, aneuromodulation system for providing electrostimulation to a patient.

FIGS. 5A-5D illustrates, by way of example and not limitation, temporalmodulation parameters as controlled by the modulation magnitude and theresulting electrostimulation waveforms.

FIGS. 6A-6F illustrates, by way of example and not limitation,morphological modulation parameters as controlled by the modulationmagnitude and the resulting electrostimulation waveforms.

FIG. 7 illustrates, by way of example and not limitation, a method forprogramming an ambulatory medical device such as an implantableneuromodulation device to provide electrostimulation to a patient.

DETAILED DESCRIPTION

In the following detailed description, reference is made to theaccompanying drawings which form a part hereof, and in which is shown byway of illustration specific embodiments in which the invention may bepracticed. These embodiments are described in sufficient detail toenable those skilled in the art to practice the invention, and it is tobe understood that the embodiments may be combined, or that otherembodiments may be utilized and that structural, logical and electricalchanges may be made without departing from the spirit and scope of thepresent invention. References to “an”, “one”, or “various” embodimentsin this disclosure are not necessarily to the same embodiment, and suchreferences contemplate more than one embodiment. The following detaileddescription provides examples, and the scope of the present invention isbased on the appended claims and their legal equivalents.

Advancements in neuroscience and neuromodulation research have led to ademand for using complex and/or individually optimized patterns ofneuromodulation energy for various types of therapies. Disclosed hereinare systems, devices, and methods for programming neuromodulationtherapy to treat neurological or cardiovascular diseases. A system mayinclude an input circuit that may receive a modulation magnituderepresenting a level of stimulation intensity, a memory that stores aplurality of gain functions associated with a plurality of modulationparameters, and an electrostimulator that may generate anelectrostimulation therapy. A controller may program theelectrostimulator with the plurality of modulation parameters based onthe received modulation magnitude and the plurality of gain functions,and control the electrostimulator to generate electrostimulation therapyaccording to the plurality of modulation parameters.

The present system may be implemented using a combination of hardwareand software designed to provide a closed-loop pain management regime toincrease therapeutic efficacy, increase patient satisfaction forneurostimulation therapies, reduce side effects, and/or increase devicelongevity. The present system may be applied in any neurostimulation(neuromodulation) therapies, including but not limited to SCS, DBS, PNS,FES, and Vagus Nerve Stimulation (VNS) therapies. With a modulationmagnitude that controls multiple modulation parameters concurrently, thepresent system is advantageous in reducing telemetry system's burden andsaving on the communication bandwidth between the IPG and theprogramming device, and simplifying the patient's interaction with theirdevice such as for programming neuromodulation therapy.

FIG. 1 illustrates, by way of example and not limitation, aneuromodulation system 100 and portions of an environment in which theneuromodulation system 100 may operate. The neuromodulation system 100may include an ambulatory system 110 and an external system 130 incommunication with the ambulatory system 110 via a communication link120.

The ambulatory system 110, configured to be associated with a body 199of a patient, may include an ambulatory device such as an implantablemedical device (IMD) 112, a lead system 114, and one or more electrodes116. The 112 may be configured to generate one or more energy modalitiesfor delivery to target tissues for medical diagnosis, or to achievedesired therapeutic effects such as to modify, restore, or improveneural or cardiac function. Examples of the energy modalities mayinclude electrical, magnetic, or other forms of energy.

In an example, the IMD 112 may include a hermetically sealed can, whichhouses sensing circuitry, electrostimulation circuitry, controlcircuitry, communication circuitry, and a battery, among othercomponents. The sensing circuitry of the IMD 112 may sense physiologicalor functional signals from the patient via electrodes 116 or varioustypes of ambulatory sensors associated with the patient. The sensingelectrodes or the ambulatory sensors may be included within, orotherwise in wired or wireless connection with, the IMD 112. In anexample, the IMD 112 may he an implantable neuromodulator device (IND)configured to provide SCS, DBS, PNS, or other types of neuromodulationtherapies. The electrostimulation circuitry may generateelectrostimulation pulses to stimulate a neural target via theelectrodes 116. In an example, the electrodes 116 may be positioned onor near a spinal cord, and the electrostimulation circuitry may beconfigured to deliver SCS to treat pain or other disorders. In anotherexample, the electrodes 116 may be surgically placed at other neuraltargets such as a brain or a peripheral neutral tissue, and theelectrostimulation circuitry may be configured to deliver brain orperipheral stimulation to treat epilepsy, chronic pain, obsessivecompulsive disorder, tremor, Parkinson's disease, or dystonia, amongother movement and affective disorders. The IMD 112 may additionally oralternatively include an implantable cardiac device coupled toelectrodes positioned at a target cardiovascular tissue or a targetneural tissue, and the IMD 112 may sense cardiac activities or generatea cardiac or neural stimulation therapy to treat a cardiovasculardisease.

In various examples, the electrodes 116 may be distributed in one ormore leads of the lead system 114 electrically coupled to the 112. In anexample, the lead system 114 may include a directional lead thatincludes at least some segmented electrodes circumferentially disposedabout the directional lead. Two or more segmented electrodes may bedistributed along a circumference of the lead. The actual number andshape of leads and electrodes may vary according to the intendedapplication. Detailed description of construction and method ofmanufacturing percutaneous stimulation leads are disclosed in U.S. Pat.No. 8,019,439, entitled “Lead Assembly and Method of Making Same,” andU.S. Pat. No. 7,650,184, entitled “Cylindrical Multi-Contact ElectrodeLead for Neural Stimulation and Method of Making Same,” the disclosuresof which are incorporated herein by reference. The electrodes 116 mayprovide an electrically conductive contact providing for an electricalinterface between the IMD 112 and tissue of the patient. Theneuromodulation pulses are each delivered from the IMD 112 through a setof electrodes selected from the electrodes 116. The selected electrodesmay form electrode combinations which define the electrodes that areactivated as anodes (positive cathodes (negative), and turned off(zero). Stimulation energy may be fractionalized over the selectedactive electrodes by defining amount of current, voltage, or energyassigned to the active electrodes. In various examples, multipleindividually defined pulses may be included in a neuromodulationwaveform, and the set of electrodes may be individually definable by theuser for each of the individually defined pulses.

Although the discussion herein with respect to the neuromodulationsystem 100 focuses on implantable device such as the IMD 112, this ismeant only by way of example and not limitation. It is within thecontemplation of the inventors and within the scope of this document,that the systems, devices, and methods discussed herein may also be usedfor programming modulation waveform and neuromodulation therapy viasubcutaneous medical devices, wearable medical devices, or otherexternal medical devices, or a combination of implantable, wearable, orother external devices.

The external system 130, via a communication link 120, may control theoperation of the IMD 112, including programming the IMD 112 withneuromodulation therapies or cardiac therapies. The external system 130may additionally receive, via the communication link 120, informationacquired by the IMD 112, such as one or more physiological or functionalsignals. In an example, the external system 130 may characterize painsensed by a patient using the physiological or functional signalsreceived from the IMD 112, and program the IMD 112 to deliver paintherapy in a closed-loop fashion based at least on the paincharacterization.

The communication link 120 may include one or more communicationchannels and intermediate devices between the external system and theIMD, such as a wired link, a telecommunication link such as an Internetconnection, or a wireless link such as one or more of an inductivetelemetry link, a radio-frequency (RF) telemetry link. The communicationlink 120 may provide for data transmission between the IMD 112 and theexternal system 130. The transmitted data may include, for example,real-time physiological data acquired by the IMD 112, physiological dataacquired by and stored in the IMD 112, therapy history data, dataindicating device operational status of the IMD 112, one or moreprogramming instructions to the IMD 112 which may include configurationsfor sensing physiologic signal or stimulation commands and stimulationparameters, or device self-diagnostic test, among others.

The external system 130 may include a dedicated hardware/software systemsuch as a programmer, a remote server-based patient management system,or alternatively a system defined predominantly by software running on astandard personal computer. By way of example and not limitation, and asillustrated in FIG. 1, the external system 130 may include a programmer180 and an intermediate controller 160. The programmer 180 may becommunicatively coupled to the IMD 112, such as via a RF telemetry link(not shown). The programmer 180 may present to a system user, such as aclinician, neuromodulation parameters for programming the IMD 112, andenable the system user to program the IMD 112 using the neuromodulationparameters. Such neuromodulation parameters may include electrodecombinations, which define the electrodes that are activated as anodes(positive), cathodes (negative), and turned off (zero), percentage ofstimulation energy assigned to each electrode (fractionalized electrodeconfigurations), and electrical pulse parameters, which define the pulseamplitude (which may be measured in milliamps or volts depending onwhether the IMD 112 supplies constant current or constant voltage to theelectrodes 140), pulse duration (which may be measured in microseconds),pulse rate (measured in pulses per second), and burst intensity (whichmay be measured as the stimulation on duration X and stimulation offduration Y). The programming of the IMD 112 may be performedintraoperatively (e.g., during implant of the IMD 112 and/or the leads130 in an operating room) or during a follow-up visit with the patient.

The programmer 180 may alternatively indirectly communicate with the IMD112 through the intermediate controller 160. The intermediate controller160 may take the form of a handheld external remote control (RC) deviceconfigured to be in communication with the IMD 112 via a bi-directionalcommunications link, such as a RF telemetry. A system user, such as thepatient, may operate the RC 260 to remotely instruct the IMD 112 togenerate electrical stimulation pulses in accordance with thestimulation parameters produced by the external system 130. Theprogrammer 180 may communicate with the RC 260 via an infraredcommunications link 170. The neuromodulation parameters provided by theprogrammer 180 may also be used to program the RC 260, so that theneuromodulation parameters may be subsequently modified by operation ofthe RC 260 in without the assistance of the programmer 180. In anexample, the programmer 180, either alone or in combination with the RC260, may control the operation of the IMD 112, such as turning on or offand programming the IMD 112 with different neuromodulation parametersets to actively control the characteristics of the electricalmodulation energy output by the IMD 112.

Portions of the IMD 112 or the external system 130 may be implementedusing hardware, software, firmware, or combinations thereof Portions ofthe IMD 112 or the external system 130 may be implemented using anapplication-specific circuit that may be constructed or configured toperform one or more particular functions, or may be implemented using ageneral-purpose circuit that may be programmed or otherwise configuredto perform one or more particular functions. Such a general-purposecircuit may include a microprocessor or a portion thereof, amicrocontroller or a portion thereof, or a programmable logic circuit,or a portion thereof. For example, a “comparator” may include, amongother things, an electronic circuit comparator that may be constructedto perform the specific function of a comparison between two signals orthe comparator may be implemented as a portion of a general-purposecircuit that may be driven by a code instructing a portion of thegeneral-purpose circuit to perform a comparison between the two signals.

FIG. 2 illustrates, by way of example and not limitation, an externalremote controller (RC) 260 that may telemetrically control the IMD 112.The RC 260, which is an embodiment of the intermediate controller 160,may allow a patient to adjust specific aspects of the neuromodulationtherapy in an ambulatory setting. The RC 260 comprises a casing 50 forhousing internal circuitry, a display screen 52, and button pad 54carried by the exterior of the casing 50. In the illustrated embodiment,the display screen 52 may include a lighted flat panel display screen,and the button pad 54 may comprise a membrane switch with metal domespositioned over a flex circuit, and a keypad connector connecteddirectly to the internal circuitry of the RC 260. In an example, thedisplay screen 52 may include a touchscreen. Further details of thefunctionality and internal components of the RC 260 are discussed inU.S. Pat. No. 6,895,280, the disclosures of which are incorporatedherein by reference.

The button pad 54 may include buttons 56, 58, 60, and 62. In thenon-limiting example as illustrated in FIG. 2, the button 56 serves asan ON/OFF button that may be actuated to turn the 112 ON or OFF. Thebutton 58 serves as a select button that may be actuated to switch theRC 260 between screen displays and/or parameters. The buttons 60 and 62may provide for setting or adjustment of modulation parameters withinthe IMD 112. The buttons 60 and 62 serve as up/down buttons that may beactuated to increment or decrement any of modulation parameters of thepulsed electrical train generated by the IMD 112, including pulseamplitude, pulse width, or pulse rate, among other modulationparameters. In various examples, the selection button 58 may be actuatedto place the RC 260 in a Pulse Amplitude Adjustment Mode, during whichthe pulse amplitude may be adjusted via the up/down buttons 60 and 62, aPulse Width Adjustment Mode, during which the pulse width may beadjusted via the up/down buttons 60 and 62, or a Pulse Rate AdjustmentMode, during which the pulse rate may be adjusted via the up/downbuttons 60 and 62.

In an example, the selection button 58 may be actuated to place the RC260 in a Modulation Magnitude Adjustment Mode. The modulation magnitude,which may take a unit-less value, represents a level of stimulationintensity. Compared to the Pulse Amplitude Adjustment Mode, the PulseWidth Adjustment Mode, or the Pulse Rate Adjustment Mode, which providefor individualized and independent adjustment of one particularmodulation parameter (such as pulse amplitude, pulse width, or pulserate, respectively), during the Modulation Magnitude Adjustment Mode,two or more modulation parameters may be concurrently adjusted using asingle modulation magnitude. The modulation magnitude may be increasedor decreased via the up/down buttons 60 and 62 For example, when thebutton 60 is actuated to increase the modulation magnitude, two or moreof the pulse amplitude, pulse width, pulse rate, or burst intensity,among other modulation parameters, may be concurrently adjusted. Othertypes of actuators other than the up/down buttons 60 and 62, such as adial, slider bar, or keypad, may be used to increment or decrement themodulation parameter.

A single modulation magnitude may control multiple modulation parametersaccording to respective parameter gain functions (PGFs) that associatethe modulation parameters with the modulation magnitudes. The PGFs maybe created and stored in a memory. The PGFs may be linear, piece-wiselinear, or nonlinear functions of modulation magnitude, and themodulation parameters may accordingly be linearly or nonlinearlycontrolled by the modulation magnitude. For example, when the PGFs arelinear or nonlinear growth functions, an increase in the modulationmagnitude may produce a proportionally stronger perceived modulationeffect. Examples of the RC 260 running in the Modulation MagnitudeAdjustment Mode and the adjustment of the modulation magnitude arediscussed below, such as with reference to FIGS. 4-6.

The RC 260 may additionally include an optional modulation selectioncontrol element 63 that allows the user to select between differentmodes. The modulation selection control element 63 may take the form ofa button, a touchscreen icon, or other types of acutators. Themodulation selection control element 63 may be repeatedly actuated totoggle the IMD 112 between the super-threshold, sub-threshold, andhybrid delivery modes. For example, the modulation selection controlelement 63 may be actuated once to switch the IMD 112 from thesuper-threshold delivery mode to the sub-threshold delivery mode,actuated once again to switch the IMD 112 from the sub-thresholddelivery mode to the hybrid delivery mode, actuated once again to switchthe IMD 112 from the hybrid delivery mode back to the super-thresholddelivery mode, and so forth. The order of the mode selection may bechanged. For example, the modulation selection control element 63 may beactuated once to switch the IMD 112 from the sub-threshold delivery modeto the super-threshold delivery mode, actuated once again to switch theIMD 112 from the super-threshold delivery mode to the hybrid deliverymode, actuated once again to switch the IMD 112 from the hybrid deliverymode back to the sub-threshold delivery mode, and so forth. Each of themodulation delivery modes may be selected by toggling the modulationselection control element 63.

FIGS. 3A-3B illustrate, by way of example and not limitation, variousexamples of an intermediate controller that may be used by a user tocontrol the generation of the modulation waveform. FIG. 3A illustratesan RC 260 that may be programmed to present a sliding scale userinterface 76 on the display screen 52 that indicate a selected value fora modulation parameter (such as pulse amplitude, pulse width, or pulserate), or a selected value for the modulation magnitude when the RC 260is placed in a Modulation Magnitude Adjustment Mode. The sliding scaleuser interface 76 may additionally include one or more of a perceptionthreshold indicator 78, or a maximum tolerable threshold indicator 90.The perception threshold indicator 78, which may be identified byletters “PT” on the sliding scale user interface 76, may correspond to aperceived paresthesia or other sensations produced byelectrostimulation. The maximum tolerable threshold indicator 90, whichmay be identified by letters “MS”, may correspond to strongeststimulation with therapeutic effects yet without causing substantialside-effects. The perception threshold indicator 78 or a maximumtolerable threshold indicator 90 may be determined through an automatedtesting process, or programmed by a system user such as a clinician.Other than the sliding scale, other textual or graphical representationsof the range as defined by the perception threshold indicator 78 or themaximum tolerable threshold indicator 90 and the selected modulationparameter values may be used, which is contemplated by the presentinventors and within the scope of the present document.

The sliding scale user interface 76 may be graduated with a scale 92with units based on a percentage of the perception threshold. In theexample as illustrated in FIG. 3A, the scale starts at 0% and increasesto 200% of the perception threshold, where the perception threshold is100%, and the maximum tolerable threshold is around 150%. Via theupldown buttons 60 and 62, a user may selectively increase or decreasethe modulation parameter or the modulation magnitude, which may bedisplayed on the sliding scale user interface 76 as a modulationparameter indicator moving to the left or to the right of the scale. Asub-perception stimulation field may be established when the modulationparameter or the modulation magnitude is set to a value less than 100%(i.e., below the perception threshold), and a supra-perceptionstimulation field may be established when the when the modulationparameter or the modulation magnitude is set to a value above 100%(i.e., above the perception threshold). The modulation parameter or themodulation magnitude may be adjusted continuously or at pre-determinedincrement or decrement steps (such as 5% increment or decrement), or beset to one of a plurality of pre-determined levels of stimulationintensity within a specific range such as between the perceptionthreshold indicator 78 and the maximum tolerable threshold indicator 90.In some examples, the perception threshold indicator 78 and the maximumtolerable threshold indicator 90 define a programmable zone within whichthe patient is allowed to adjust the modulation parameter value or themodulation magnitude. If an attempt is made to program the modulationparameter or the modulation magnitude outside the programmable zone, analert, in a form of text, graph, sound, or other media formats, may beissued.

In addition to or in lieu of adjusting the modulation parameter or themodulation magnitude relative to the perception threshold “PT”, themodulation parameter or the modulation magnitude may be adjusted to avalue relative to a baseline electrophysiological measurement, such aslocal field potential (LCP), evoked compound action potential (ECAP),among other bio-potential measurements. The sliding scale user interface76 may include the scale 92 with units based on a percentage of thebaseline electrophysiological measurement. Via the up/down buttons 60and 62, a user may increase or decrease the modulation parameter or themodulation magnitude to a level relative to the baselineelectrophysiological measurement, and therefore establish asub-perception or supra-perception stimulation field at a desirablefield strength.

FIG. 3B illustrates an RC 260 that includes the selection button 58 thatmay be actuated to place the RC 260 into a Modulation Program SelectionMode. A plurality of selectable modulation programs may be displayed onthe display screen 52, such as modulations programs #1, #2 and #3illustrated by way of example and not limitation. A user may select amodulation program from the list, or deselect a previously usedmodulation program, such as via the up/down buttons 60 and 62 or otherselection means such as touch-screen selection. Each modulation programmay include an aggregation of a plurality of modulation parameters (suchas pulse amplitude, pulse width, or pulse rate, among others) withrespectively programmed values. Various modulation programs may beassociated with different physiological states or physical activitylevels. In an example, the selectable modulation programs may include amodulation program for sleep state, a modulation program for awakeningstate, and a modulation program for a specific physical activity level.

FIG. 4 illustrates, by way of example and not limitation, aneuromodulation system 400 for providing electrostimulation to apatient, which may be an embodiment of the neuromodulation system 100.The neuromodulation system 400 may include an implantable neuromodulator410 and an external system 430, which are embodiments of the IMD 112 andthe external system 130, respectively. The external system 430 may becommunicatively coupled to the implantable neuromodulator 410 via thecommunication link 120.

The implantable neuromodulator 410 may include one or more of a sensorcircuit 411, a modulation magnitude equalizer 412, an electrostimulator413, and a controller 414. The sensor circuit 411 may be coupled toelectrodes or various types of ambulatory sensors associated with thepatient, and sense physiological or functional signals from the patient.Examples of the physiological signals may include cardiac, hemodynamic,pulmonary, neural, or biochemical signals, among others. Examples of thefunctional signals may include patient posture, gait, balance, orphysical activity signals, among others. In various examples, anaccelerometer may be used to detect an activity intensity or activityduration. A tilt switch, an accelerometer, or a thoracic impedancesensor may be used to detect posture or position. Gyroscope,magnetoresistive sensors, inclinometers, goniometers, electromagnetictracking system (ETS), sensing fabric, force sensor, strain gauges, andsensors for electromyography (EMG) may be used to measure motion andgaits.

The modulation magnitude equalizer 412 may produce a plurality ofmodulation magnitudes based on the sensed physiological or functionalsignals. A modulation magnitude may represent stimulation intensity. Inan example, the modulation magnitude may be a unit-less number such asfrom 0 to 10, where “0” indicates no perception of stimulation, and “10”indicates a high and intolerable stimulation intensity. The modulationmagnitude equalizer 412 may establish a correspondence between thestimulation intensity (such as at the magnitude of 0 and the magnitudeof 10) and a collection of signal metrics generated from the sensedphysiological or functional signals. In some examples, thecorrespondence may additionally include signal metrics of the sensedphysiological or functional signals at other intermediate modulationmagnitudes, such as between 0 and 10. The established correspondence maybe represented as a lookup table, an association map, or other datastructures that may be stored in a memory in the implantableneuromodulator. Based on the established correspondence, for aphysiological or functional signal is sensed from the patient, acorresponding modulation magnitude may be determined. The modulationmagnitude may be forwarded to the external system 430. A system user maydetermine whether to increase or decrease the modulation magnitude viathe user interface 431.

Alternatively, modulation magnitude equalizer 412 may be implemented inthe external system 430. The physiological or functional signals sensedfrom the sensor circuit 411, or the signal metrics generated thereof,may be transmitted to the external system 430. The modulation magnitudeequalizer 412 may produce a corresponding modulation magnitude for usein programming the neuromodulation therapy. The implantableneuromodulator 410 may include a communication circuit that enablesbi-directional communication between the implantable neuromodulator 410and the external system 430 via the communication link 120.

The electrostimulator 413 may be configured to generateelectrostimulation energy to treat pain or other neurological disorders.In an example, the electrostimulator 413 may deliver spinal cordstimulation (SCS) via electrodes electrically coupled to theelectrostimulator 413. The electrodes may be surgically placed at aregion at or near a spinal cord tissue, which may include, by way ofexample and not limitation, dorsal column, dorsal horn, spinal nerveroots such as the dorsal nerve root, and dorsal root ganglia. The SCSmay be in a form of stimulation pulses that are characterized by pulseamplitude, pulse width, stimulation frequency, duration, on-off cycle,pulse shape or waveform, temporal pattern of the stimulation, amongother stimulation parameters. Examples of the stimulation pattern mayinclude burst stimulation with substantially identical inter-pulseintervals, or ramp stimulation with incremental inter-pulse intervals orwith decremental inter-pulse intervals. In some examples, the frequencyor the pulse width may change from pulse to pulse. The electrostimulator413 may additionally or alternatively deliver electrostimulation toother target tissues such as peripheral nerves tissues. Theelectrostimulator 413 may deliver transcutaneous electrical nervestimulation (TENS) via detachable electrodes that are affixed to theskin. In another example, the electrostimulator 413 may deliver deepbrain stimulation (DBS) via electrodes surgically placed at a braintissue. In yet another example, the electrostimulator 413 may delivercardiac or neural stimulation therapy to treat a cardiovascular disease.

The controller 414, coupled to the electrostimulator 413, may controlthe generation and delivery of the neuromodulation energy. Thecontroller 414 may control the generation of electrostimulation pulsesaccording to specific programming of stimulation parameters, such asprovided by the programmer circuit 437 in the external system 430. Thestimulation parameters may include temporal modulation parameters suchas pulse amplitude, pulse width, pulse rate, or burst intensity,morphological modulation parameters respectively defining one or moreportions of stimulation waveform morphology (such as amplitude, pulsewidth, or other modulation parameters) of different phases or pulsesincluded in a stimulation burst, or spatial modulation parameters suchas selection of active electrodes, electrode combinations which definethe electrodes that are activated as anodes (positive), cathodes(negative), and turned off (zero), and stimulation energyfractionalization which defines amount of current, voltage, or energyassigned to each active electrode and thereby determines spatialdistribution of the modulation field. The controller 414 may control theelectrostimulator 413 to generate electrostimulation energy to establishsub-perception or supra-perception stimulation field. In some examples,the controller 414 may control the electrostimulator 413 to generatehybrid electrostimulation that includes simultaneous sub-perception orsupra-perception stimulation fields at one or more stimulation sites.

The external system 430 may include a user interface 431, a memory 434,and a programmer circuit 437. The user interface 431 may be associatedwith either the programmer 180 or the intermediate controller 160 asillustrated in FIG. 1, or be distributed between the programmer 180 andthe intermediate controller 160. The user interface 431 may include aninput circuit 432 and an output unit 433. The input circuit 432 mayenable a system user, such as a clinician or a patient, to provideprogramming information for one or more modulation parameters. Examplesof the input circuit 432 may include a keyboard, on-screen keyboard,mouse, trackball, touchpad, touch-screen, or other pointing ornavigating devices such as the selection and navigation buttons 58, 60and 62 in the intermediate controller 160.

In an example, the input circuit 432 may be configured to receive, suchas from a system user, modulation magnitude representing a level ofstimulation intensity. As previously discussed, a single modulationmagnitude may concurrently control two or more modulation parameterssuch as the pulse amplitude, pulse width, pulse rate (also known aspulse frequency), burst intensity, or other morphological parameters. Insome examples, the input device 432 may be configured to allow userinput of the modulation magnitude only within a specific programmablezone, which may be defined by one or both of a lower bound (M_(min)) andan upper bound (M_(max)). The lower bound M_(min) may be associated witha perception threshold that is sufficient to cause perceived paresthesiaor other sensations caused by the electrostimulation. The upper boundM_(max) may be associated with a maximum tolerable threshold withtherapeutic effects and without causing substantial side-effects. Thelower and upper bounds M_(min) and M_(max) may be graphically identifiedon the display of the output unit 433, such as the identifiers “PT” or“MS” on the sliding scale user interface 76 of the RC 260, asillustrated in FIG. 3A. An alert may be triggered if a system userattempts to program the modulation magnitude outside the programmablezone.

In some examples, the input device 432 may be configured to allow userinput of the modulation magnitude represented by a value relative to abaseline electrophysiological measurement, such as LCP, ECAP, or otherbio-potential measurements. The modulation magnitude may be set to apercentage of the baseline electrophysiological measurement such as viathe RC 260, and establish a sub-perception or supra-perceptionstimulation field at a desirable field strength. In an example of hybridelectrostimulation where both sub-perception and supra-perceptionstimulation fields are to be established for stimulation one or moretarget sites, the input device 432 may be configured to allow user inputof a first modulation magnitude relative to a baselineelectrophysiological measurement, and a second modulation magnituderelative to a perception threshold “PT”. The controller 414 may controlthe electrostimulator 413 to deliver electrostimulation according to thefirst modulation magnitude to establish the sub-perception stimulationfield, and to deliver electrostimulation according to the secondmodulation magnitude to establish the supra-perception stimulationfield.

The output unit 433 may include a display screen to display informationsensed by the implantable neuromodulator 410. This may include thesensed physiological and functional signals, the signal metrics, or themodulation magnitude generated from the modulation magnitude equalizer412. The information may be presented in a table, a chart, a diagram, orany other types of textual, tabular, or graphical presentation formats,for displaying to a system user. The presentation of the outputinformation may include audio or other human-perceptible media format.In some examples, the modulation magnitude generated from the modulationmagnitude equalizer 412 may be presented on the display, and the systemuser to choose to confirm, reject, or otherwise modify the modulationmagnitude before it is used for programming the neuromodulation therapy.

The memory 434 may store a plurality of parameter gain functions (PGFs)435 {f1,f2, . . . , fN}, respectively defined for a plurality ofmodulation parameters {X1, X2, . . . , XN}. Each PGF may define acorrespondence between values of a modulation parameter Xi and aplurality of modulation magnitudes M. That is, the modulation parameterXi may be defined as a function (fi) of the modulation magnitude M:Xi=fi(M). The PGFs may be linear, piece-wise linear, or non-linearfunctions of the modulation magnitude M. As previously discussed, themodulation magnitude M may be represented as a value relative to aperception threshold or relative to a baseline electrophysiologicalmeasurement. In an example, the PGF for one modulation parameter (e.g.,Xi) may be defined as a function of modulation magnitude M relative tothe perception threshold, while the PGF for a different modulationparameter (e.g., Xj) may be defined as a function of modulationmagnitude M relative to the baseline electrophysiological measurement.In an example, stored in the memory 434 may include a first PGF (f1) forpulse amplitude P_(A) where P_(A)=f1(M), a second PGF (f1) for pulsewidth P_(W) where P_(W)=f2(M), and a third PGF (f3) for pulse rate P_(R)where P_(R)=f3(M), and a fourth PGF (f4) for burst intensity B_(I) whereB_(I)=f4(M). Other than the temporal modulation parameters, the PGFsstored in the memory 434 may additionally or alternatively include oneor more of morphological modulation parameters or spatial modulationparameters. Examples of the PGFs for modulation parameters are discussedbelow, such as with reference to FIGS. 5-6.

The programmer circuit 437, which is coupled to the user interface 432and the memory 434, may generate values for the plurality of modulationparameters based on the modulation magnitude received from the inputcircuit 432 and the PGFs stored in the memory 434. For example, if amodulation magnitude of M=3 is provided by a system user, values of themodulation parameters {X1, X2, . . . , XN} may be determined accordingto the respective PGFs, that is, Xi=f1(3), for i=1, 2, . . . , N. Themodulation parameter values may be transmitted to the implantableneuromodulator 410 via the communication link 120. The controller 414 ofthe implantable neuromodulator 410 may program the electrostimulatorwith the modulation parameters, and control the electrostimulator 413 toelicit the electrostimulation therapy according to the programming ofthe plurality of modulation parameters.

The programmer circuit 437 may additionally or alternatively select ordeselect a modulation program based on the user specified modulationmagnitude. As illustrated in FIG. 4, stored in the memory 434 mayinclude modulation programs 436. The modulation programs may beassociated with different physiological states or physical activitylevels. In an example, the selectable modulation programs may include afirst modulation program for sleep state, a second modulation programfor awakening state, and a third modulation program for a specificphysical activity level. A modulation program may include an aggregationof a plurality of modulation parameters with respectively programmedvalues. The modulation programs may different from each other by thenumber or type of modulation parameters. For example, a first modulationprogram designed for awakening and resting state may have a differentmodulation waveform (as defined by the temporal modulation parameters)than a second modulation program designed for sleep state, and may havea different electrode combinations or modulation energyfractionalization than a third modulation program designed for aphysically active state.

The selected modulation program (including the modulation parameterswith respectively programmed values) may be transmitted to theimplantable neuromodulator 410, where the controller 414 may program theelectrostimulator 413 with the selected modulation program, and controlthe electrostimulator 413 to elicit the electrostimulation therapyaccording to the selected modulation program, or to withhold theelectrostimulation therapy according to the deselected modulationprogram.

In various examples, at least some part of the memory 434 and theprogrammer circuit 437 may be implemented within the implantableneuromodulator 410, such that the determination of the modulationparameter values may be executed within the implantable neuromodulator410. In an example, personalized PGFs may be created for a particularpatient and stored in a memory (not shown) within the implantableneuromodulator 410. The programmer circuit 437, which may also residewithin the implantable neuromodulator 410, may receive the modulationmagnitude from the input circuit 432 and determine the modulationparameter values according to the PGFs associated with the modulationparameters. Similarly, the modulation programs 436 may be personalizedfor individual patient and stored in the memory within the implantableneuromodulator 410, and the programmer circuit 437 may determine themodulation program for use in electrostimulation therapy based on themodulation magnitude from the input circuit 432. Transmitting throughthe communication link 120 the modulation magnitude rather than valuesof a multitude of modulation parameters may be advantageous in saving onthe communication bandwidth. The personalized. PGFs may be individuallydetermined or updated according to patient needs or sensor feedback.

FIGS. 5A-5D illustrates, by way of example and not limitation, temporalmodulation parameters as controlled by the modulation magnitude and theresulting electrostimulation waveforms. The electrostimulation waveformis created from a base pulse of a biphasic pulse as illustrated in 510A.Various electrostimulation waveforms may be generated by altering and/orrepeating the biphasic pulse according to the temporal modulationparameters defined by the respective PGFs. The electrostimulationwaveforms may be displayed on a display of the output unit 433, or onthe programmer 180 or the intermediate controller 160. Neuromodulationenergy may be generated at the electrostimulator 413 in accordance withthe electrostimulation waveforms.

The temporal modulation parameters include pulse amplitude (FIG. 5A),pulse rate (also known as pulse frequency, FIG. 5B), and burst intensity(FIG. 5C), each of which is determined as respective PGFs of themodulation magnitude. By way of non-limiting examples, the PGFs forpulse amplitude, pulse rate, and burst intensity in FIGS. 5A-5C are allgrowth functions of modulation magnitude. As such, the modulationparameters increase proportionally to an increase in the modulationmagnitude. The modulation magnitude is represented by a unit-less valuebetween 0 and 10. At a high modulation magnitude of M=10, theelectrostimulation waveforms may be characterized by a high pulseamplitude 510A, a high pulse rate 510B, or a high burst intensity 510C.When the modulation magnitude is reduced to a medium high level of M=7,the electrostimulation waveforms may be characterized by a medium highpulse amplitude 520A, a medium high pulse rate 520B, or a medium highburst intensity 520C. As the modulation magnitude is further reduced toa medium low level of M=4, the electrostimulation waveforms may becharacterized by a medium low pulse amplitude 530A, a medium low pulserate 530B, or a medium low burst intensity 530C. Finally at a lowmodulation magnitude of M=2, the electrostimulation waveforms may becharacterized by a low pulse amplitude 540A, a low pulse rate 540B, or alow burst intensity 540C. The temporal modulation parameters, such aspulse amplitude, pulse width, pulse rate, or burst intensity, determinethe amount of energy delivered to the target tissue. In accordance withPGFs being growth functions of modulation magnitude, the amount ofenergy delivered to the tissue and thus the aggressiveness of theelectrostimulation therapy may be proportionally controlled by thesingle parameter of modulation magnitude.

FIG. 5D illustrates concurrent adjustment of more than one modulationparameter, which, by way of example and not limitation, may include bothpulse amplitude and burst frequency. Both the PGF for pulse amplitudeand the PGF for pulse rate are growth functions of modulation magnitude,such that both the pulse amplitude and the pulse rate would decrease asthe modulation magnitude decreases. As illustrated in FIG. SD, theelectrostimulation waveforms 510D, 520D, 530D and 540D are characterizedby concurrent decrease in pulse amplitude and pulse rate, correspondingto successively decreasing modulation magnitudes of 10, 7, 4 and 2.

FIGS. 6A-6F illustrates, by way of example and not limitation,morphological modulation parameters as controlled by the modulationmagnitude and the resulting electrostimulation waveforms. Themorphological modulation parameters may define various portions of theelectrostimulation waveform morphology. The electrostimulation waveformmay include a base pulse in the form of uni-phasic, biphasic, ormulti-phasic pulse, or other user defined pulse shape or morphology. Inthe examples illustrated in FIGS. 6A-6F, the base pulse is a biphasicwaveform including a first pulse 605 and a second pulse 606. Amplitude(A1) of the first pulse 605 is a first PGF (f1) of the modulationmagnitude M, and amplitude (A2) of the second pulse 606 is a second PGF(f2) of the same modulation magnitude M, that is, A1=f1(M) and A2=f2(M).In some examples, modulation parameters other than pulse amplitude, suchas pulse width or other morphological parameters, may alternatively oradditionally be defined for the first and second pulses.

The electrostimulation waveforms, including the amplitudes A1 and A2respectively for the first and second pulses, may be determined by thePGFs (f1 and f2) and the modulation magnitude. In FIG. 6A, the PGFs f1and f2 (601A and 602A, respectively) are linear growth functions. Assuch, A1 and A2 both decrease proportionally to the reduction of themodulation magnitude from 100% to 75%, 50%, 25%, 10%, and 0% of themaximal modulation magnitude (M_(max)), as shown in respectiveelectrostimulation waveforms 610A-660A.

In FIG. 6B, the PGF f2 (602B) is a linear growth function, and the PGFf1 (601B) is a piece-wise linear function with an initial linear growthportion at low M values between 0-25% of M_(max), and a subsequentconstant gain when M exceeds 25%*M_(max). As shown in electrostimulationwaveforms 610B-660B, when the modulation magnitude changes from 100% to75%, 50%, 25%, 10%, and 0% of M_(max), A2 decreases proportionally tothe reduction of the modulation magnitude. However, A1 of the firstpulse remains constant until the modulation magnitude drops below25%*M_(max), where A1 starts to decrease proportionally to the reductionof the modulation magnitude.

In FIG. 6C, the PGF f1 (601C) is a linear growth function, and the PGFf2 (602C) is a piece-wise linear function, which has an initial lineargrowth portion at low M values between 0-50%*M_(max), and a subsequentlinear decay portion when M exceeds 50%*M_(max). As shown inelectrostimulation waveforms 610C-660C, when the modulation magnitudechanges from 100% to 75%, 50%, 25%, 10%, and 0% of M_(max), A1 decreasesproportionally to the reduction of the modulation magnitude. However, A2of the second pulse increases proportionally when the modulationmagnitude decrease down to 50%*M_(max), at which point A1 begins todecrease proportionally to the reduction of the modulation magnitude.

In FIG. 6D, both the PGFs f1 and f2 (601D and 602D, respectively) arepiece-wise linear functions. The PGF f1 (601D) comprises an initiallinear decay portion at low M values between 0-50%*M_(max), and asubsequent linear growth portion when M exceeds 50%*M_(max). The PGF f2(602D) comprises an initial linear growth portion at low M valuesbetween 0-50%*M_(max), followed by a linear decay portion when M exceeds50%*M_(max). The maximal gain of A2, which can be reached at50%*M_(max), is set to about half the base value of A2. As shown inelectrostimulation waveforms 610D-660D, when the modulation magnitudechanges from 100% to 75%, 50%, 25%, 10%, and 0% of M_(max), A1 decreasesproportionally to the reduction of the modulation magnitude until50%*M_(max) of the modulation magnitude is achieved, at which point A1then starts to increase proportionally to the reduction of themodulation magnitude. A2 of the second pulse increases proportionallywhen the modulation magnitude decrease down to 50%*M_(max), and thendecreases proportionally to the reduction of the modulation magnitude.

In FIG. 6E, the PGF f1 (601E) comprises four portions corresponding tofour consecutive segments of modulation magnitudes between0-100%*M_(max). The first portion is zero gain such that Al stays atzero for modulation magnitudes of 0-10%*M_(max). The second portion is afast linear growth portion where A1 increases from 0 to about 40% of thebase amplitude corresponding to modulation magnitudes of 10-25%*M_(max).The third portion is a slow linear growth portion where A1 increasesfrom 40% to about 60% of the base amplitude corresponding to modulationmagnitudes of 25-75%*M_(max). The fourth portion is a plateau where A1maintains at about 60% of the base amplitude when the modulationmagnitude exceeds 75%*M_(max). The PGF f2 (602E) also comprises fourportions corresponding to four consecutive segments of modulationmagnitudes. The first portion is a linear growth portion where A2increases linearly from about 50% of the base amplitude at themodulation magnitude of 0 to the full base magnitude at the modulationmagnitude of 40%*M_(max). The second portion is a plateau where A2maintains at the full base amplitude for modulation magnitudes of40-60%*M_(max). The third portion is a linear decay portion where A2decrease from the full base amplitude to about 90% of the base amplitudecorresponding to modulation magnitudes of 60-75%*M_(max). The fourthportion is a plateau where A1 maintains at about 90% of the baseamplitude when the modulation magnitude exceeds 75%*M_(max). Theelectrostimulation waveforms 610E-660E corresponding to variousmodulation magnitudes at 100% to 75%, 50%, 25%, 10%, and 0% of M_(max)illustrates the A1 and A2 as determined by the PGFs 601E and 602E.

In FIG. 6F, both the PGFs f1 and f2 (601F and 602F, respectively) arepiece-wise linear functions. The PGF f1 (601F) comprises five portionscorresponding to five consecutive segments of modulation magnitudesbetween 0-100%*M_(max). The first portion is a linear growth portionwhere A1 elevates from zero to full base amplitude corresponding tomodulation magnitudes of 0-20%*M_(max). The second portion is a plateauwhere A1 maintains a full base amplitude corresponding to modulationmagnitudes between 20-40%*M_(max). The third portion is a linear decayportion where A1 drops from full base amplitude down to zerocorresponding to modulation magnitudes of 40-60%*M_(max). The fourthportion is a zero-gain portion where A1 stays at zero for M valuesbetween 60-80%*M_(max). The fifth portion, which corresponds to M valuesbetween 80-100%*M_(max), includes a linear growth portion where A1 againelevates from zero to full base amplitude. The PGF f2 (602F) comprisesan initial portion of zero gain corresponding to modulation magnitudesof 0-40%*M_(max). Subsequently, there is a linear growth portion whereA1 elevates from zero to full base amplitude corresponding to modulationmagnitudes falling between 40-60%*M_(max). For modulation magnitudesexceeding 60%*M_(max), A2 reaches a plateau at the full base amplitude.The electrostimulation waveforms 610F-660F corresponding to variousmodulation magnitudes at 100% to 75%, 50%, 25%, 10%, and 0% of M_(max)illustrates the A1 and A2 as determined by the PGFs 601F and 602F.

FIG. 7 illustrates, by way of example and not limitation, a method 700for programming an ambulatory medical device (AMD) such as animplantable neuromodulation device to provide electrostitnulation to apatient. The method 700 may be used to provide neuromodulation therapy,such as SCS, DBS, PNS, FES, or VNS therapies, to treat pain or variousneurological disorders. The method 700 may additionally or alternativelybe used to provide electrostimulation therapy to treat a cardiovasculardisease or other health disorders.

The method 700 may be implemented in a medical system, such as theneuromodulation system 400. In an example, at least a portion of themethod 700 may be executed by an ambulatory device such as the IMD 112,or the implantable neuromodulator 410, among other implantable orwearable devices. In another example, at least a portion of the method700 may be executed by an external programmer or remote server-basedpatient management system, such as the external systems 130 or 430 thatmay be communicatively coupled to the ambulatory device. In someexamples, steps included in the method 700 may be distributed between anambulatory device and an external device in communication with theambulatory device.

The method 700 begins at step 710, where a modulation magnitude may bereceived from a system user. The programmer 180 or the intermediatecontroller 160 as illustrated in FIG. 1, or the RC 260 in FIG. 2, may beused to provide the modulation magnitude. In an example, a user mayplace the intermediate controller 160 (or RC 260) in a ModulationMagnitude Adjustment Mode, and provide or select an appropriatemodulation magnitude using control buttons, dial, slider bar, or otheractuators on the RC 260, as illustrated in FIGS. 2 and 3A.

The modulation magnitude represents a level of stimulation intensity.The modulation magnitude may be a unit-less number such as between 0 and10, where “0” indicates no perception of stimulation, and “10” indicatesa high and intolerable stimulation intensity. The modulation magnitudemay be associated with two or more modulation parameters such as thepulse amplitude, pulse width, or pulse rate (also known as pulsefrequency), such that two or more modulation parameter may beconcurrently programmed using a single modulation magnitude. In someexamples, the modulation magnitude provided by the system user may berequired to be within a specific magnitude range such as defined by oneor both of a lower bound (M_(min)) and an upper bound (M_(max)). Thelower bound M_(min) may be associated with a perception threshold thatis sufficient to cause perceived paresthesia or other sensations causedby the electrostimulation. The upper bound M_(max) may be associatedwith a maximum tolerable threshold with therapeutic effects and withoutcausing substantial side-effects. In some examples, the modulationmagnitude may be represented by a value relative to a baselineelectrophysiological measurement, such as LCP, ECAP, or otherbio-potential measurements. In various examples, a first modulationmagnitude relative to a baseline electrophysiological measurement may beused to establish a sub-perception stimulation field, and a secondmodulation magnitude relative to a perception threshold “PT” may be usedto establish a supra-perception stimulation field. The sub-perceptionand supra-perception stimulation may be delivered simultaneouslyaccording to a hybrid electrostimulation program.

At 720, a plurality of parameter gain functions (PGFs) associated withrespective modulation parameters may be established. Each PGF may definea correspondence between values of a modulation parameter and modulationmagnitudes. In an example, the PGFs may be individually andindependently defined for the respective modulation parameters,including but not limited to PGFs for pulse amplitude, pulse width,pulse rate, burst intensity, pulse morphological parameters, orelectrode combination and energy fractionalization, such as the asillustrated in FIGS. 5A-5D. In another example, the PGFs may be definedfor various portions of an electrostimulation waveform morphology,including but not limited to PGFs for various phases of a bi-phasic ormulti-phasic electrostimulation waveform, such as the PGFs asillustrated in FIGS. 6A-6F. The PGFs may be may be linear, piece-wiselinear, or non-linear functions. In an example, a PGF or a portion ofthe PGF may be a linear or nonlinear growth function of a modulationparameter, such that an increase in the modulation magnitude wouldresult in proportional increase in the modulation parameter. In anotherexample, a PGF or a portion of the PGF may be a linear or nonlineardecay function of a modulation parameter, such that an increase in themodulation magnitude would result in proportional decrease in themodulation parameter. The PGFs thus created may be stored in a memorysuch as within the programmer 180 or the intermediate controller 160,and can be retrieved upon a request command.

At 730, values for the modulation parameters may be determined accordingto the respective PGFs at the specific modulation magnitude. Themodulation parameter values may be determined by the programmer circuit437 such as implemented within the programmer 180, as illustrated inFIG. 4. A740, the modulation parameter values thus determined may beused to program an electrostimulator such as included within theimplantable neuromodulator 410 or within the IMD 112. Electrostimulationenergy may be generated at 750 according to the programmed modulationparameters. The electrostimulation energy may be used to treat chronicpain or other neurological disorders or cardiovascular disease. In anexample, spinal cord stimulation (SCS) may be delivered via electrodessurgically placed at a region at or near a spinal cord tissue. Inanother example, transcutaneous electrical nerve stimulation (TENS) maybe delivered via detachable electrodes affixed to the skin. In yetanother example, deep brain stimulation (DBS) may be delivered viaelectrodes surgically placed at a brain tissue. In some examples,cardiac or vagal nerve stimulation may be delivered to treat acardiovascular disease such as heart failure.

In some examples, the method 700 may be used to select or deselect amodulation program based at least on the user specified modulationmagnitude as provided at 710. A modulation program may include anaggregation of a plurality of modulation parameters with respectivelyprogrammed values. The modulation programs may be associated withdifferent physiological states or physical activity levels. In anexample, the selectable modulation programs may include a firstmodulation program for sleep state, a second modulation program forawakening state, and a third modulation program for a specific physicalactivity level. Various modulation programs may include different numberor different type of modulation parameters, which may be selected fromtemporal modulation parameters such as pulse amplitude, pulse width,pulse rate, or burst intensity, morphological modulation parametersrespectively defining one or more portions of stimulation waveformmorphology such as amplitude of different phases or pulses included in astimulation burst, or spatial modulation parameters such as selection ofactive electrodes, electrode combinations, stimulation energyfractionalization (such as current or voltage distribution) over theselected active electrodes which determines the spatial distribution ofthe modulation field.

For each modulation program, PGFs for the modulation parametersassociated with that modulation program may be established at 720. PGFsin one modulation program may be different than the PGFs in anotherdifferent modulation program. For example, a modulation program forresting state may include electrostimulation with different waveformmorphology or electrode configuration than a modulation program for aphysically active state. The user specified modulation magnitude asprovided at 710 may then be used to select a modulation program, and thevalues for the modulation parameters associated with the selectedmodulation program may be determined at 730. The electrostimulator maythen be programmed at 740 with the selected modulation program, andelectrostimulation energy may be generated at 750 according to theselected modulation program. In some examples, an existing modulationprogram may be deselected at 730, and the electrostimulation therapyaccording to the deselected modulation program may be withheld frombeing delivered to the patient.

In some examples, the method 700 may be used to modify an existingelectrostimulation therapy such as by adjusting the modulation magnitudeat 710 and/or updating the PGFs for one or more modulation parameters ora modulation program at 720. In an example, the adjustment of themodulation magnitude and/or the update of one or more PGFs may be basedon patient physiological or functional response to the delivery ofelectrostimulation therapy which may be sensed using sensors configuredto sense physiological or functional signals from the patient. If thephysiological or functional response satisfies a specified conditionsuch as reduction of pain symptom or improved neurological orcardiovascular function, the existing electrostimulation therapy isdeemed effective. Otherwise, a feedback-control of therapy may beinitiated. By way of example and not limitation, in a closed-loop painmanagement system, if an existing pain therapy does not effectiverelieve the pain, then the modulation magnitude may be increased at 710to increase the perceived therapy intensity such as by increasing theamount of energy delivery. Additionally or alternatively, the PGFs forone or more modulation parameters or a modulation program may be updatedat 720, such as by increasing one or more of pulse amplitude, pulsewidth, or pulse rate; configuring different pulse morphology; orreconfiguring the electrode combination such as selecting differentactive electrodes and redistributing the energy fractionalization.

The above detailed description includes references to the accompanyingdrawings, which form a part of the detailed description. The drawingsshow, by way of illustration, specific embodiments in which theinvention may be practiced. These embodiments are also referred toherein as “examples.” Such examples may include elements in addition tothose shown or described. However, the present inventors alsocontemplate examples in which only those elements shown or described areprovided. Moreover, the present inventors also contemplate examplesusing combinations or permutations of those elements shown or described.

Method examples described herein may be machine or computer-implementedat least in part. Some examples may include a computer-readable mediumor machine-readable medium encoded with instructions operable toconfigure an electronic de⁻vice to perform methods as described in theabove examples. An implementation of such methods may include code, suchas microcode, assembly language code, a higher-level language code, orthe like. Such code may include computer readable instructions forperforming various methods. The code may form portions of computerprogram products. Further, in an example, the code may be tangiblystored on one or more volatile, non-transitory, or non-volatile tangiblecomputer-readable media, such as during execution or at other times.Examples of these tangible computer-readable media may include, but arenot limited to, hard disks, removable magnetic disks, removable opticaldisks (e.g., compact disks and digital video disks), magnetic cassettes,memory cards or sticks, random access memories (RAMs), read onlymemories (ROMs), and the like.

The above description is intended to be illustrative, and notrestrictive. For example, the above-described examples (or one or moreaspects thereof) may be used in combination with each other. Otherembodiments may be used, such as by one of ordinary skill in the artupon reviewing the above description. The scope of the invention shouldbe determined with reference to the appended claims, along with the fullscope of equivalents to which such claims are entitled.

What is claimed is:
 1. A method for providing electrostimulation to apatient via an ambulatory medical device (AMD) communicatively coupledto an external programmer device, the method comprising: receiving, viathe external programmer device, at least a single user inputcorresponding to a modulation magnitude; determining, via the externalprogrammer device, respective values for a plurality of modulationparameters based on the received single user input of the modulationmagnitude; and providing, via the AMD, an electrostimulation therapy tothe patient in accordance with the determined respective values for theplurality of modulation parameters.
 2. The method of claim 1, whereindetermining the respective values for the plurality of modulationparameters includes using a plurality of gain functions each defining acorrespondence between a modulation parameter and the modulationmagnitude.
 3. The method of claim 1, wherein determining the respectivevalues for the plurality of modulation parameters includes using aplurality of lookup tables each defining a correspondence between amodulation parameter and the modulation magnitude.
 4. The method ofclaim 1, wherein the plurality of modulation parameters includes atleast a temporal modulation parameter and a spatial modulationparameter.
 5. The method of claim 4, wherein the temporal modulationparameter includes at least one of a stimulation amplitude, a width ofstimulation waveform, a stimulation rate, a duty cycle, or a burstintensity.
 6. The method of claim 4, wherein the spatial modulationparameter includes at least one of an election of an active electrode,an electrode combination activate as an anode, an electrode combinationactivated an cathode, a turned-off electrode, or a stimulation energyfractionalization over a number of electrodes.
 7. The method of claim 4,wherein: the temporal modulation parameter includes a stimulationamplitude, the stimulation amplitude being a growth function of themodulation magnitude; and the spatial modulation parameter includes astimulation energy fractionalization representing a size of a modulationfield, the size of the modulation field is a growth function of themodulation magnitude.
 8. The method of claim 1, wherein the plurality ofmodulation parameters includes at least a first modulation parameter formodulating sub-perception stimulation and a second modulation parameterfor modulating supra-perception stimulation.
 9. The method of claim 8,wherein the received single user input of the modulation magnitude isrelative to a baseline electrophysiological measurement.
 10. The methodof claim 8, wherein the received single user input of the modulationmagnitude is relative to a perception threshold.
 11. The method of claim8, comprising receiving user input of a first and second modulationmagnitudes, wherein: determining the respective values for the pluralityof modulation parameters includes determining a first value for thefirst modulation parameter based on the received first modulationmagnitude, and determining a second value for the second modulationparameter based on the received second modulation magnitude; andproviding the electrostimulation therapy includes providing asub-perception stimulation in accordance with the first modulationparameter taking the first determined value, and providing asupra-perception stimulation in accordance with the second modulationparameter taking the second determined value.
 12. The method of claim11, wherein the first modulation magnitude is represented by theperception threshold scaled by a first factor less than 100%, and thesecond modulation magnitude is represented by the perception thresholdscaled by a second factor greater than 100%.
 13. The method of claim 12,wherein the second modulation magnitude takes a value between theperception threshold and a maximum tolerable threshold.
 14. The methodof claim 8, wherein providing the sub-perception stimulation includes:providing a first sub-perception stimulation in accordance with thefirst modulation parameter taking a value based on a perceptionthreshold scaled by a first factor less than 100%; and providing asecond sub-perception stimulation in accordance with the firstmodulation parameter taking a value based on a perception thresholdscaled by a second factor less than 100%, the second factor differentfrom the first sub-threshold factor.
 15. A system for providingelectrostimulation to a patient, the system comprising: an externalprogrammer device configured to receive at least a single user inputcorresponding to a modulation magnitude; a memory configured to store acorrespondence between values of a modulation parameter and values ofthe modulation magnitude; a controller configured to determinerespective values for a plurality of modulation parameters based on thereceived single user input of the modulation magnitude and the storedcorrespondence; and an electrostimulator configured to generate anelectrostimulation therapy for delivery to the patient in accordancewith the determined respective values for the plurality of modulationparameters.
 16. The system of claim 15, wherein the plurality ofmodulation parameters includes at least a temporal modulation parameterand a spatial modulation parameter.
 17. The system of claim 16, wherein:the temporal modulation parameter includes a stimulation amplitude, thestimulation amplitude being a growth function of the modulationmagnitude; and the spatial modulation parameter includes a stimulationenergy fractionalization representing a size of a modulation field, thesize of the modulation field is a growth function of the modulationmagnitude.
 18. The system of claim 15, wherein the plurality ofmodulation parameters includes at least a first modulation parameter formodulating sub-perception stimulation and a second modulation parameterfor modulating supra-perception stimulation.
 19. The system of claim 18,wherein: the external programmer device is configured to receive a firstand second modulation magnitudes; the controller is configured todetermine a first value for the first modulation parameter based on thereceived first modulation magnitude, and determining a second value forthe second modulation parameter based on the received second modulationmagnitude; and the electrostimulator is configured to generate asub-perception stimulation in accordance with the first modulationparameter taking the first determined value, and to generate asupra-perception stimulation in accordance with the second modulationparameter taking the second determined value.
 20. The system of claim15, comprising an implantable device that includes theelectrostimulator, wherein the controller is included in the externalprogrammer device or the implantable device.